Aspiration of gastric contents

Signs
Gastric contents in the oropharynx, severe hypoxemia, increased airway pressures, bronchospasm, copious tracheal secretions, coughing, laryngospasm, rhonchi, dyspnea, hyperventilation.

Treatment
Tracheal suctioning prior to positive pressure ventilation.
Trendelenberg, right lateral tilt.
Ventilation 100% FiO2, PEEP.
Bronchoscopy, lavage, suction.
Cancel elective surgery.
ICU ventilator.
Antibiotics based on gram stain.
Bronchodilators.
Steroids (no proven benefit).
ECMO.
Lung Transplant.

Lab
Lavage sample for pH, Gram stain, and culture.
Chest x-ray.

ASPIRATION PROPHYLAXIS
Guidelines
Metoclopramide reduces gastric volume. Does not decrease risk of aspiration in healthy patients.
H2 blockers (cimetidine, famotidine, ranitidine, nizatadine) and proton pump inhibitors reduce gastric acidity and volume. Do not decrease risk of aspiration in healthy patients.
Antacids decrease gastric acidity. Do not decrease risk of aspiration in healthy patients.

ANAPHYLAXIS / ANAPHILACTOID REACTION

Anaphylaxis is an acute multi-system severe type I hypersensitivity allergic reaction. The term comes from the Greek words ἀνά ana, means against, and φύλαξις phylaxis, means protection.

Signs & Symptoms
Cardiovascular:
Hypotension, tachycardia, dysrhythmias
Pulmonary:
Bronchospasm, cough, dyspnea, pulmonary edema, laryngeal edema, hypoxemia.
Dermatologic:
Urticaria, facial edema, pruritus.
Neurologic:
Sense of impending doom.

Diagnosis
Serum Tryptase level (released with histamine from mast cells). Draw levels at 1 & 24 hours after event. (Nl <25 mcg/L).

Treatment
Discontinue offending agent.
FiO2 100%.
Epinephrine (mainstay of therapy, mast cell stabilization, hemodynamic support, bronchodilator).
IV 50-100 mcg, may need repeat dosing.
If no IV access, 200-500 mcg IM or SQ (may repeat x 1).
Fluid resuscitation.

Secondary treatment:
Diphenhydramine 50 mg.
Albuterol MDI/Neb as needed for bronchospasm.
Catecholamine infusion.
Conside alpha-agonist after second dose of epinephrine.
Intravenous steroids (dexamethasone 20 mg or methylprednisolone 100 mg).

Brief case : Airway Fire

Airway fires are an uncommon but real and devastating complication of tracheostomy.

Prevention
Use ETT resistant to laser ignition, low FiO2, no N2O, ETT cuff with blue dye/saline.
Limit laser duration.
Saline soaked pledgets in airway.
Have water to extinguish fire.

Treatment
Stop laser.
Stop ventilation.
Discontinue oxygen.
Remove burning ETT.
Douse airway fire with water (IV bag).
Suction debris from airway.
Ventilate with 100% oxygen by face mask.
Reintubate trachea.
Examine airway with bronchoscope to assess injury.
Consider steroids and antibiotics.